The Often-Overlooked Health Behavior

(upbeat music) - Bye, this is Jim Nickman. - And this is Brian Elbowl, and you are listening to Conversations about Healthcare Delivery in the United States, a podcast series featuring our conversations with prominent experts, innovators, and leaders in the health sector. So this episode we discussed the linkages between health behavior and chronic disease burden in the United States, important and exciting, health behavior change programs, and initiatives for improving helpful sleep. We also look at exciting technological advances impacting personalized and population level health behaviors. Our special guest today is Dr. Aziz Asias. Dr. Asias is interim chair of the Department of Informatics and Health Data Science at the University of Miami Miller School of Medicine. He's also a founding director of the Media and Innovation Lab, Associate Director of the Center for International Sleep Insurcutian Science, and Director of Population Health Informatics at the Institute for Data Science and Computing. But first, a message from our sponsor. - Neurological conditions like schizophrenia and Alzheimer's disease are complex and represent some of the greatest challenges of our time. Because these conditions very widely and are chronic in nature, they have a significant impact on patients and care partners. That's why Bristol Meyer's Squib is re-entering the field of neuropsychiatry. Our goal is to change how people with neurological conditions are treated, both clinically and socially, helping them to thrive. Visit BMS.com to learn more. - Azizzi, thank you so much for being here. - Thanks for having me. - So Jim and I want to start with a big picture question, right? So tell us, what's the state of health behaviors in the United States right now? Big picture, how are we doing? Are we making good progress? Are our Americans acting in helpful ways? Like tell us how we're doing? - Well, I hope I really wanted to come in and say, well, the state of the union is in good hands. But that's a bit kind of bombastic. So here's a deal that what we do know and these are dates are produced by CDC and other agencies that are highly reputable. That if you were to look at what I consider the four core health behaviors in nutrition or diet and sleep and stress and physical activity that what we've seen over the years is that we've seen a decline in the level of adherence to many of these areas. So I'll just kind of focus on let's say diet and nutrition. It's been shown that around 2019 and there is no reason to think that these trends how discontinued is that from 2019 that when you serve the adults to see what their fruit and vegetable intake on consumption was, that this actually declined over a period of time from about 12% to 10%. So that means that we're not getting fruit and vegetables and that's just with adults. So what we do know particularly too and that adults aren't eating well, kids aren't eating well either. And so it's fear to say that our kids aren't eating well as well. And that's just kind of fruit and vegetable consumption. I know for you both of you either have done incredible work looking at what are some policy changes that can be made to improve this. But I think your work just highlighting where the food deserts are really kind of frames and puts into sharp focus the state of our fears that even though we have this decline, what might be driving this decline? And it's access to healthy foods and fruits and vegetables. So that's just with nutrition. Let's look at physical activity. That if you look at the CDC, the CDC, Numbos says that about 25% of the population reported that they were physically inactive. And that's primarily kind of set into our behaviors. Now that doesn't mean that these people actually mean in a 75% of these individuals get good exercise or adequate exercise. It's just that these folks are just sedentary. But when you peel the layer of that, you look at racial ethnic minority groups that they are the ones who actually don't engage with physical activity and the appropriate exercise that could confer the most best or the most health benefits. So for example, Numbos show that Asian Americans actually have the lowest prevalence of physical inactivity. And then when you look at non-Hispanic blacks as well as Hispanic blacks, they actually have the greatest prevalence of physical inactivity. And so when you connect that with all these other maladies and chronic health conditions, you can see that when you look at physical activity which really protects folks from, protects folks from, you know, poor health and promotes good health that there are some groups that are not getting the best and the most. Let's focus on sleep. It's been shown that we have a sleep crisis and this is very near and dear to me 'cause my own work focuses on sleep, on circadian, science is I've hold that impacts health. And it's been shown that on average about a third of our country actually don't get in sleep. And this is self-report and we've seen an other community-based type of work including our own work, that these numbers that the CDC actually has might be a little bit suppressed because these are self-report. When you really dig in on people, the people are actually not getting in sleep. And some of you are a view as me ask, what is that? It primarily means if you're not getting seven to nine hours of sleep on average, it means therefore that you're not getting the optimal amount of sleep that would confer health benefits. And then when you peel the layers even more, you look demographically across geographic region on racial ethnic minorities. When you look at the different states, you have states like Colorado that has the lowest prevalence of short sleep. And this is sleep that less than seven hours. When you look at states like West Virginia that they have the highest prevalence of insufficiency at near 43%. What does this mean? It means they're four, there are some states where their communities don't get to sleep. And so this is why most of us believe that sleep in many ways is not just a health behavior or a fundamental physiological state and condition that can promote health, but it's also a social justice issue. Because if you look at those states like West Virginia, they actually are considered to have some of the worst social economic outcomes as well as health outcomes. And if you track that along with poor sleep, then you start to see some kind of correlations. And we're not saying causality, but there's some correlation. And last but not least, let's look at stress. You know, stress is a major issue. And especially in the world that we're currently in, we are hyperarolles, hypostimulating, and our lives are even more demanding than they were previously, especially in the wake of COVID. And what we have seen particularly over the years is that rates of worry and nervousness and anxiety is at an all time high at about 12%. No, that doesn't mean that people don't experience more, but these are clinically characterized numbers. And particularly in terms of the amount of adults who feel depressed, that has also risen to about 5% as well. So it goes to show overall that when you look at diet and nutrition, when you look at physical activity or inactivity and exercise, and when you look at sleep and you look at stress that the state of our lifestyle on our health behaviors are not good enough. - Yeah, quite a depressing picture. When you think about what's in you alluded to some of this, when you think about what's driving some of these behaviors and you touched on its element, particularly driving them maybe in a not good direction, what is it? Is it these sort of policy and environmental factors that's changing? Is it a culmination of other things? Technology here, you talked about a lot. Like what is it that we think is driving some of these bad behaviors or declines in these behaviors? - That's an excellent question. It's complex. And as a result of that, I hope I'll be able to paint a complex picture in a very digestible way to your audience. - So what we know is that when you look at health behaviors, that health behaviors are driven by a wide variety of different factors, your biology, and that could include your physiology, as well as your DNA, your genetic predisposition and composition. It also includes clinical risk factors, behavioral risk factors. It also includes psychosocial factors as well as well as environmental factors. So let me just kind of go through each of those and just lay out some specific ways and some specific components. So let's look at your biology on your genetic composition. one of the things that we have done in our old work as well as others. And let's just say sleep for itself. Use sleep as an itself. That many people don't notice that your sleep pattern as well as quality sleep, texture of your sleep and how much sleep you actually get and how rest did you feel. It's partly due to your DNA. You could be a morning person or an evening person and this really operates our own what we call your circadian rhythm. But many of that your circadian rhythm is really governed by your genes. So let me just get a little bit more concrete here. So your circadian rhythm has to do with these biological clocks. There's this master clock that essentially helps to communicate with all the other clocks that are in our muscles or cells or workouts. And it's like a simple as how they are able to synchronize all the different physiological and behavioral activities. What we have found is that individuals who are from you know or are from African ancestry, they are circadian rhythm. Actually is shortened where it doesn't follow a 24-hour cycle like you know their European and white cultivars. Under some reasons as to why some of us believe it could be because of you know you know historical epigenetic processes where it significance a moment of stress and stresses. Even from 400 years ago literally got under the skins of individuals that in many ways affected your DNA composition, affected your sleep cycle and affected actually when the initiate sleep, how they maintain sleep and also how they feel rested. So that's a biological reasoning behind that as to how that impacts your sleep. Let's look at clinical factors. Well some folks who are on medications, some medications can have some really adverse side effects and those unfortunately can disrupt your sleep and therefore it becomes this vicious cycle where the medication that you're on or some condition may actually help or support or promote disruption of your sleep and then that can exacerbate your health condition. So that's another clear example as to how clinical factors can impact that. Let's focus on behavioral factors. Well if you are you know engaging in stressful activities and if you're working two different jobs and all of those things then you don't have the opportunity to sleep as well and so we often tend to say you don't want to you know go to bed in a very stressed state because that can cause you to have fragmented sleep and disrupted sleep and not good quality sleep. Let's focus on type of social factors like social determinants of health. What we've been able to show and I think I've provided an earlier prevalence where you look at social economic status when you look at the amount of noise pollution and light pollution and poor air quality. It's almost like a really nice you know correlation in and I don't mean nice enough in and it's a bad public health issue. I just meant for some scientists or some geeks scientists where you start to see how air quality impacts of one's sleep. How noise pollution impacts your sleep and so it's important for us to be aware of that and last but at least environmental factors as I said these are critical areas that we need to be aware. So it's a very multi-lead perspective as to and I can say the same thing physical activity and diets and stress management. Yeah so I think that gives you a sense of the complexity and also shows you if you really want to tackle this problem you're going to have to go after lots of different potential contributing factors. I'm policy too. I don't want to lead because I know you are a huge policy person. That's a huge component I'll be talking about. So the only thing you're sort of I think you might have left out is tobacco and alcohol. And that's what I was going to talk about too. Those are just to come up jump on jump spline like you. So you gave us some of the more health favors that can be protected. What about some of the risk you want, right? Absolutely, absolutely. I think those we can apply the same framework. A multi-level perspective looking at whole why is it that someone may engage in smoking tobacco or consuming tobacco because their other methods are always consuming tobacco. And it could be because of stressors. It could be because of some kind of potential hard wiring of this predisposition to the need that nicotine in some ways. It could be where you live as well in terms of your environment. If you live in an area where the local, you know, Diego, or those of you who are in the New York area or a local you know, grocery place that you're more likely to have, you know, more options for tobacco than vegetable and fruit choices. And so here is it that you can see in terms of consumption of tobacco or smoking or any other type of health behavior. It's really a multi-leared approach. And we have to be able to look at that. And so to kind of address, I think you're maybe follow a question because I think I know you are both very well is how then should policy, you know, tackle this multi-level nature because here is it as a behavioral scientist and for this fantastic book chapter, thanks to you, but how do we, because many people believe that when you're talking about behavior, there is this performatory assumption that we need to focus on personal responsibility. And I don't mean that to be political either. But what we are saying is that you can't just lay the full responsibility and blame at the seat or at the feet of individuals that someone's decision, someone's psychology of in terms of motivation and social support and all of those things that are critical. These really significant impact their ability to lead healthy lifestyles. And it also, you know, kind of sends them to an apartment where they're more likely to engage in risky health behaviors. Yeah, yeah. So maybe we could talk a little bit more about sleep because it's one of the areas of focus that you have. Tell us specifically how that does influence health, right? How does sleep change, chronic disease outcomes or change the overall health of populations? I really don't like this conversation because I only slept six hours last night. You know, I think for some, some people will say that's not bad. What we're seeing is a sleep deprivation crisis. There are some people only get four. Some people who only get five and consistently. And I've had to powe through their days. So I think, you know, just to kind of center your question, you know, Dr. Ogle, it's a real nice idea that you know, how does sleep impact health? And so I oftentimes say it is like I'm speaking to my kids and I know I'm not, but it's from head to toe. You know, sleep impacts you from head to toe. And I can go through each other's. Let's focus on brain health. Many studies have shown that the lack of sleep and good adequate sufficient sleep can have deleterious effects in terms of acute and chronic. Acute meaning, it can't significant impact your ability to perform certain cognitive tasks like memory and processing information and judgment. And then if this persists meaning sleep deprivation persists over time, it can actually lead to certain neurological conditions like dementia, like Parkinson's. And the reason it on the science behind that is that particularly for, you know, dementia, that sleep, it's so critical and vital for our existence, that the body, which is, I think I see the body, I have so much awe for the human body and for the human being. I think that's why I became a psychologist because I was never good with my hands really, I don't know what to fit scars. But I felt like the human being was back from where I could lift the hood off the human being and understand the inner machinations of the mind what made them take. And that's what, you know, being a behavioral scientist does. And so in many ways, sleep allowed me to understand it actually impacts someone's brain health. So here's what we know that sleep is so critical for the clearance of different debris and protein, what we call toxic protein, I'm called beta amyloids. Beta amyloids are implicated in increased risk for Alzheimer's disease, which is a, you know, the most prevalent form of dementia. And so what happens is that sleep works almost like a vacuum where it, you know, it really clears and sucks up or washes the brain from all the debris of all those brain cells working over that day, all that hard can not processing nine, all of those things that you do, the sleep allows you to clean that's okay. If you don't get added to sleep, then all sorts of what happens is that you have an accumulation of the beta amylide protein and toxins and sleep impacts hard to help, you know, so one of the things that we know is that when we sleep, that sleep is important. For many reasons, one is to restore homeostasis, which is keeping a very equal, healthy biologic called environment. It also is important for energy conservation, and it also has some brain health properties in terms of memory consolidation under light. So what sleep does in this ear of a heart health is that we typically, when we rest our body particular blood pressure dips, you know, over that given period of time, but if your body is in this constant state activation, then what happens is that your blood pressure will remain high. When your blood pressure remains high, consistently, you can have a significant wearing and tearing of several vascular parts of your body, like veins on arteries, and that can lead to heart attacks, that can lead to hypertension, that can lead to stroke. So this whole sleep works, and I can go on and on, as to whole sleep significantly impacts major vital organs on physiological processes. So that's great, very helpful, and you talked about the multi-faceted way that various factors come to cause these things like negative sleep. So when you think about particularly the role of the healthcare system or the healthcare delivery system, how can it tackle something like this, if at all, what role does this system have in helping something like sleep and meaning for what? Yeah, that's an excellent question, and so it's a timely question because I am having to make the case for repositioning all healthcare systems should be pervails, as well as deliverers of healthcare, in my new role as a chair of the Department of Informatics and Health Medical Science. And so the goal is this, that healthcare systems need to really think hard as to do the only cureable to our patients, meaning patients who lay in our beds or patients that we see in inpatient settings, because if we are interested in our current patients and our community who could potentially be future patients, then we can't just take this very myopic approach where we only are focused on the people who are just in front of us. Instead, this is where public health and population health strategies are critical for the sustenance of any healthcare system. And if we really want to, in many ways, ensure that the value chain that healthcare systems provide are optimized, whether being in terms of ensuring that people get the right treatment at the right time, the right dosage within context, or are we going to lead in public health prevention programs and strategies, and I think that's important. And so what healthcare systems can do is ensuring that one, we fully understand how health behaviors are critical to the treatment and the clinical outcomes of your patients. That's important. And if you take this multi-level approach, then you then have to then refashion how your teams are composed. So it shouldn't just privilege the folks who are only managing clinical outcomes. But here is that we can bring in social workers and case managers, because we recognize it's fully that social determinants of health and other types of factors are as important if not more important in the clinical outcomes of their patients, as well as the management of your disease, as well as adherence to treatments. And so if we create what I call multi-disciplinary solution shops, whereby each person is bringing in their own perspective, tackling the different multifierious factors that are actually impacting health, then it will allow health systems to treat the whole person. But we can't just leave it there. Instead, we also must focus on innovation and technology whereby we are not adding more under plates of people who are already in a healthcare system. So what does it mean? We've got to have to grow the tend of we consider as healthcare, part of the healthcare teams. And one of the things that I've advocated is that we need to upskill and repurpose individuals to help. So kind of people who are kind of own aids, how can we upskill them so that they can be impervious or they can deliver remote health monitoring solutions? Maybe they can help people to age in place better. And I think that's all we kind of need, healthcare systems need to one, really recenter what our focus is and realize that prevention is critical, but put resources in, in solution, multi-disciplinary solution shops that can help with management and prevention. But at the same time, broaden the tent, ensuring that the treatment teams that we bring on are individuals who can be on the front lines and upskilling individual act well to do that. It's interesting just taking it back to policy a little bit, it sounds to me like, you know, I mean, physicians are under a lot of pressure to go faster and see more people. But maybe the only way we can really get people to sort of look more broadly is to pay for outcomes and not just time or service and absolutely, you know, and then all of a sudden people can say, gee, I'm going to have better outcomes if I address social determinants or behavior and that might change it, but it's hard, you know. It is hard, and I think, you know, I don't want to get in trouble, but I think we have to resent who is the protagonist in this, you know, relationship. And then the other question is, should all this be happening at kindergarten or when kids are three years old or, I mean, are we attacking it too late to have an impact? I wonder. I think that's a good point. I think when you talk about kind of lifestyle and health behavior, yes, it's important, but I think in our chapter, we kind of address this a little where there is this assumption that if we provide people with more information, then they'll change and they'll lead healthy lives. And that's not the case. There is not a one-to-one correlation between more information and change in behavior. It's multi-level. And so we have to be very, this is why I said we have to resent who the protagonist is. This is why I love technology and innovation because there's a framework called human-centered design. And if we meet the consumer and the patient, the protagonist, then our entire modest operandi changes whereby it's no longer focusing on how we can maintain the delivery, but how is it that we can be a little bit more innovative to meet the needs of people? And so clinical outcome is important. Well, I can tell you this, some patients say, yeah, I want my blood pressure to be reduced. Well, I also want to enjoy life, right? I want to still eat the cultural foods that I grew up with that reminds me of my grandma. So you're telling me to adhere to the Mediterranean lifestyle, then that's not going to cut it. So one of the things that we have done as being very intentional about this is, you know, not to not, you know, the Mediterranean lifestyle, I love, you know, olive oil and all things Mediterranean, but the problem is that we are providing recommendations that are one practically and psychologically and culturally discordant to who some people are. And so especially in a place like New York City or Miami where we are, which both as two of the most cosmopolitan cities, we can't tell someone to put down rice and beans. And I'm not trying to be stereotypical. We have to comment and say, what are some nutritional value and properties that we can take to these communities? Because this is weird in many ways, many people have said to research on science and healthcare has blindly been prejudiced because we only study a particular reference group. And that reference group doesn't look like everyone in the community. And so we need to re-center things and to find value in the foods and the practices that people engage in because that's who they are. And so that's kind of where I think, you know, you know, healthcare systems while trying to ensure that they provide value-based care is important, but how is it that we can better engage? So you provided a nice life course, perspective reaching folks earlier than little, but, you know, there's so many kind of tectonic shifts that occur over the lifespan that we must provide guardrails along the way to ensure that we make it easier. easier for people and make it more accessible for people to lead healthy loads. So I mean, this is a great point, right? Really from the perspective of meeting people where they are, understanding their personal preferences, culture, values, race ethnicity, that's driving certain aspects of their life is really important. Do we do we know how to get health systems of pay attention to that stuff? Or do we know how to get society to pay attention to that stuff overall? Yeah, I think that's that's a great question and I think this is why having you know, we want to get the solution and dialogue with esteemed thinkers like yourself is important because I'm not standing from a place that we have got to figure it out either. I think we're all on this pursuit of making it right. And what I oftentimes call restoring the covenant, the most secret covenant that we have with our community and our patients is do no harm and making sure that health care is for all. And so I think for me, I would look at the top different. I think there needs to be leadership, whether be federal leadership, local government leadership, and leadership after our respective institutions as well. It's just important that we need leadership. And you may ask, what did they need to what's the focus of that? What did they need to do? I think we, as I said, we need to really be serious about recentering who the protagonist is in this relationship and it's our patients, it's the community. It's to serve, it's to serve them. And we have to find every possible way of serving these individuals. So in terms of solutions and mechanism, this is why you know, I think, you know, America and other free markets have done well, because this is going to spur innovation. So a lot of the work that we're doing here in Miami and the media and innovation lab and my new role as chair of the Department of Information Health Data Science is, how is it that we can re-imagine academic medicine health care? And we know that it's not a small beat, what it entails and what it must include and ought to, when it uses a stronger word, what it ought to include, is pad big magic shifts across five core verticals, education, research, clinical care, venture, and service and outreach. And I'll just kind of highlight what the valid prop is for each of those. So in terms of education, what we're doing here at the University of Miami is that we are training and creating the next generation of innovators. What I consider a new phenotype of clinician and scientists. We call them clinician innovators and scientists innovators. We're creating massive amount of programming and educational programming as to how to innovate. We teach folks how to do the scientific method for the most part. Maybe I love the engineer method. No one knows what innovation method is at all. And so here is it know that the students that we have at the undergraduate level at medical schools are allowed to help and in scientific and in getting PhDs and alike. These are millennials and genius years. They want to impact right no. So how do we create the world and create an educational system for them? That is future proof. That's for tomorrow. And so we're very bullish about that in terms of creating that content and making sure that innovation runs through. And not just for that, we're talking need management, lower management as well. That if you're going to create a system that tries to re-center and do right by the patient or for the patient, that innovation just has to be part on part of what we do. Research focusing on precision on personalized population health and framework that we created, which is a translational approach that shows how we can actually spur discovery to treatment solutions and discovery is on a continuum of insight. Using our best analytical tools and data. And so I mean, my role in the new department is how is it that we can get the right data? How can we collect it? Well, how can we cure it and collate it? And you know, analyze it, interpret it and disseminate it. We are providing a roadmap as to how to do that and it really frame falls under the the auspices of how we understand data and we see data as resume. Looking at all these different domains, how do we capture that for the patient? How does that even get into Epic? And that's the problem that many people ask pragmatically. How does that get into Epic? And so this is where we need disruptive thinking because we have a good system of electronic medical records. But what if we create kind of federated types of information on data whereby we don't necessarily synchronize data from activities, track us for patients into Epic because there are no actionable insights that can come as a as a derivative of that. But it will allow treatment teams to better contextualize the patients. So we're having more information. So instead of telling Ms. Jones, hey, Ms. Jones, you got to eat some fruits and vegetables. Why not say Ms. Jones? You know, there's a coupon at C-tone where you can get fruits and vegetables at that discounted price. Wouldn't that be good for Ms. Jones? Where you're not just telling her and throwing out into the wild to say, hey, you just need to go ahead and get fruits and vegetables. And so that's what we're trying to do with research and data. This is why we need to enhance data and find ways in which we can help it to accentuate what we do. And then in terms of research, making sure that we democratize and decentralize research, making it more inclusive. In clinical, cure, vertical, we are focused on giving the right treatment to the right person at the right time, the right dosage across different contexts. And we're focusing on three court areas. First, we want to be leaders in remote health monitoring solution, because I think remote health monitoring solutions are in court time. Recognizing that there's a digital divide. So what we've done in our own research is to team up with companies like T-Mobile. We give people smart phones and a life like, so that they can, you know, have to worry about those things at all. Also, making sure that health can be done at home, because most of health actually occurs outside of the physical brick and mortar health systems, right? So how is it that we can create more wraparound supports for individuals? And last but not least, digital therapeutics is on ear that we're focused on, clinical care and then venture. Venture is key. Spinning things out, spinning things in. We want to make sure that our school is old-point, you know, to this area as well. We're, we are laying out for our faculty. It's good to write papers, good to get Nobel prizes and stuff, but I think not all the grill of dissemination is not just to analyze your data and send it out there. Information is not enough. It's a product. What products can come out of this? And it doesn't mean a device or anything like that, but it could be a process. It could be a policy. What can come out of this? That is the holy grill of dissemination. And then last but not least, service on outreach. What we're saying is this, if we want people to be better consumers and active participants and stakeholders in health care and delivery, we got to have to engage in and we're going to have to make them to be better consumers. So we've done several programs with large, I think one of the largest digital mental health programs here in Florida, um, um, called stem cell, science, technology, engineering, math, and social emotional learning, where we know it's almost 70%, almost 70% rather, of the community in Florida, they don't live close to a mental health practitioner. And so who gets to deal with that? The teacher is the educators, the guidance counselors, and they already are overwhelmed. And yeah, I dare say it to be a little bit politically, you know, provocative handcuffed by state legislature as to what they can provide in schools in Florida. So we said, all right, well, let's provide some digital mental health programming and social emotional learning, supporting teachers and students alike. And that's what we're doing. And then we're focusing on digital literacy for all the adults because they are going to be the consumers of health here. And as people know, and they've always said this, they want to age and please, they don't want to go to a whole, they want to be with their families, they want to be by themselves, they want to maintain their live-life independence. So that's what we're doing. And just the center of that is health behavior on technology. Yeah, that's very, that's great. So maybe in thinking about that kind of technology and innovation overall, you know, one of the things that that leads to is careers for people who want to work in those areas, right? So, so if you're a student or someone out there who wants to really engage in health behaviors, maybe the technology angle is one of them. Maybe you could talk a little bit about that. But if not, just how, you know, if you're someone who cares about health behaviors, where should you be looking to? Oh, that's not a good question. I think that's still concrete, right? It keeps me honest, right? So that's I'm not opining. I think here's a, you can use health behavior in every asset and basket on any job, right? One of the things that we do know is that I think it provides you a basic understanding of the human being, right? And why the team? But more concretely, technology is an area, right? So in terms of device development and improving processes and the like, that's important. Population health management is critical, where behavioral scientists can be fully engaged in in as well, or if they want to be on the front lines, be a case manager, or a provider, a behavioral science health behavior is critical to have that perspective as to what makes that patient or that individuality. And you can apply it to a wide variety of different things. If you want to be a manager, you need to have a behavioral approach, because it's important you're dealing with people, you're dealing with your teams. If you want to do innovation, it's critical. Why? Because all products have a user in mind. And so you need to understand the psychology, what the value prop is, what the pain point is for those individuals. And so a behavioral science background is critical for a whole sub-deprecate years. And I was just only able to highlight a select view. Fantastic. So, go ahead, Jim, let me get a wrap up. Okay, you know, I have two, I'm going to ask you two questions that want you to ask a real briefly. Okay, I guess it will. I mean, okay, so the version of this is the last round. So the first one is, like, is America very different from other countries? Are we doing a worse job or a better job of dealing with this problem? No, it's unbelievable. It is global, instead of like that. Okay, so here's my species question, and then I want to stumble you on it. So, you know, so humans do all these crazy things. You know, we smoke and we drink and we, you know, don't sleep all those things. Are we different from other species or are rabbits and tigers do the same thing? Some of them leave bad healthy lives and some, so I'm trying to figure out this is a unique thing to humans or not. It's not. It's not. I think, you know, this is a great question, by the way. I think what separates us, as you all know, is higher order cognitive processing and be able to effectuate your fate and destiny and to control that through those higher order cognitive function is something that a squirrel probably can't do or a deer. So, say in many ways there are those stark differences, but when you understand a human being as social and understand species as social, I think that's where there's commonality. So that's one thing. But also, even at an individual instinctual level, there is some commonality as well that in the face of fear and threat that we will respond and that's our reflexes, right? Now, how do you situate that in terms of some of the things that we spoke about earlier? Well, I think I just shared with you many of the health behaviors and the risky health behaviors, oftentimes, occur under the environment and ostracists of being feared or stressed or something bad. And so, what you may see as a risky health behavior may be a reflex or a response to fear and threat and endangerment, right? Whether be conscious or unconscious. So I think that's one commonality. I think the commonality that I spoke about earlier in terms of how we operate our social beings, I think that's where you have seen a lot of cross-pollination on cross-perpetalization at looking at how different species operate. I think I was, I don't know if this is okay to say, but I was watching 60 minutes and you're looking at wolves and how wolves evolve into dogs and how the evolution of dogs being man's or humankind, you know, best friend, how that sociology and that sociological evolution, in many ways, not only made them our best friends, but no, we're doing studies on understanding cancer and all these rare diseases because they have evolved so close to us physiologically that we can learn from how they respond to treatments to understand a human being. So that's one area as well. But you know, when you look at kind of herd mentality is one area where as human beings, I think we don't do a really good enough job. So like our herd mentality is when you have a pack of wolves, they're going to band together and tackle an issue because there is threat or there's an opportunity for food. I think for us, because of that higher order of executive function, that we suspend what oftentimes is good for the group in our own interest, right? And so this is why you have people who, unfortunately, will have what we call this fusion of responsibility, like something bad would be happening and they have this bystandering effect as opposed to leaping to this heroic, which we call heroic, but technically it shouldn't be heroic. It should be in our nature because our other animal species counterparts will respond in that way appropriately to defend the life and the sanctity of the group. So you see those commonalities, those start differences, but also I hope the example that are shared a loady to understand the nuances and idiosyncrasies of whole context impacts and how our whole our higher order of functioning allows us to do choose and decide to suspend our greatest instincts of protecting others and the likes. I hope that was somewhat clear, clear but complicated, but that's what we've got. That's right. Thank you so much, this has been a fantastic conversation and I think you've given us lots of think about, but also some real like paths towards solutions and I think really the most important message is that Jim should probably sleep more. No problem. Thank you so much. Thank you so much. It's been great. Thank you. Hello. Now a message from Springer Publishing. Variety, flexibility, accessibility and the freedom to choose what works for your busy life. That's the Springer Publishing way. Is it Springer Pub.com/PublicHealth or content and tools to move forward in your career? Use code podcast for 25% off your next purchase. So Jim, what did you think of our conversation with Aziz? Well, I learned a lot, you know, I don't pretend to be an expert on this topic, but I learned a lot and also he was a colleague of ours before. He's clearly a couple of long ways doing really interesting stuff, which is great, great to know and I think everybody who watches this will see that they learned. Yeah, I thought he did a really nice job of laying out the complexity of some of these behaviors. I mean, human behavior is a complex and complicated thing that has many things driving it. And I think that makes it hard to exactly know how to intervene in compelling ways that I thought he did a really nice job of talking through how various sectors, the policy sector for one, the policy sector for one, the healthcare sector for another can have a real impact here, but how well these things really need to work together. Right. You know, it's interesting. I think in one of these podcasts, we should look at the differences between behavioral health, social determinants of health, population health, there are all these terms out there that I think some of our audience will have a hard time distinguishing and should clarify some stuff. Yeah, which kind of intersect and interconnect and interesting, but even more complicated ways. I also thought the focus on technology is a really interesting one. I know it's part of his easy work. And I think, you know, it obviously is clear that it can be a problem in a driver of some of this, but also a solution in certain ways as well as if you lost the right way. Yeah. And it's interesting in our last chapter on futures. We spent a fair amount of time on, wow, technology is really happening in a big way in changing and getting excited. Yeah. Okay. Great stuff. Okay, great. This concludes another great episode of Conversations about Healthcare Delivery in the United States. Thanks for listening and stay tuned for more episodes and additional resources related to the textbook. Conversations about Healthcare Delivery in the United States have been brought to you Respringer Publishing Company LLC, all rates reserved. No part of this podcast may be reproduced, stored in a retrieval system, or transmitted in any form, or by any means, without the prior permission of Springer Publishing Company LLC.